Form

development application including the proposed change.
   No
    Yes – the completed Sections 1 and 2 of Part 5 (Referral details) of DA Form 1 as it relates to the change application is
provided with this application. Where referral is required for matters relating to building work the referral checklist for
building work is also completed.

10) Information request under Part 3 of the DA Rules
   I agree to receive an information request if determined necessary for this change application
   I do not agree to accept an information request for this change application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:
 that this change application will be assessed and decided based on the information provided when making this change application
    and the assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to
    accept any additional information provided by the applicant for the change application unless agreed to by the relevant parties
 Part 3 of the DA Rules will still apply if the application is an application listed under section 11.3 of the DA Rules.
Further advice about information requests is contained in the DA Forms Guide.


11) Further details
   Part 7 of DA Form 1 is completed as if the change application was a development application and is provided with this
application.

PART 6 – CHECKLIST AND APPLICANT DECLARATION
12) change application checklist
I have identified the:
      responsible entity in 3); and
      for a minor change, any affected entities; and                                                 Yes
      for an ‘other’ change all relevant referral requirement(s) in 9)
Note: See the Planning Regulation 2017 for referral requirements
For an ‘other’ change application, the relevant sections of DA Form 1 – Development                   Yes
details have been completed and is attached to this application                                       Not applicable
For an ‘other’ change application, where building work is associated with the change                  Yes
application, the relevant sections of Form 2 – Building work details have been
completed and is attached to this application                                                         Not applicable

Supporting information addressing any applicable assessment benchmarks is attached
to this application
Note: This includes any templates provided under 23.6) of DA Form 1 that are relevant as a
result of the change application, a planning report and any technical reports required by the         Yes
relevant categorising instrument(s) (e.g. the local government planning scheme, State Planning
Policy, State Development Assessment Provisions). For further information, see DA Forms
Guide: Planning report template.
Relevant plans of the development are attached to this development application
Note: Relevant plans are required to be submitted for all relevant aspects of this change             Yes
application. For further information, see DA Forms Guide: Relevant plans.


24) Applicant declaration
    By making this change application, I declare that all information in this change application is true and correct.
    Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications from
the responsible entity and any relevant affected entity or referral agency for the change application where written
information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions Act 2001.
Note: It is unlawful to intentionally provide false or misleading information.
Privacy – Personal information collected in this form will be used by the responsible entity and/or chosen assessment
manager, any relevant affected entity or referral agency and/or building certifier (including any professional advisers which
may be engaged by those entities) while processing, assessing and deciding the change application.

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                                                                                            Planning Act Form 5 - Change application form
                                                                                                                 Version 1.0—3 July 2017